‘Really hard for physicians’: Is your patient experiencing heavy menstrual bleeding?

In assessing for heavy menstrual bleeding, physicians should avoid leading with the obvious question, according to an Ontario hematologist.“What I know is really important is never to start the conversation with a patient with, ‘Do you have heavy menstrual bleeding?’ Why? Because you’re inviting her to lead with her bias,” said Dr. Michelle Sholzberg, division head of hematology-oncology at St. Michael’s Hospital, in Toronto, and director of the hospital’s coagulation laboratory.“And if she’s bled heavily her whole life, I ask you all, what is going to be her answer? ‘No.’ And when she says ‘no,’ and I stop asking questions, the conversation is over,” Dr. Sholzberg said in a presentation at the Black Physicians’ Association of Ontario’s annual symposium in late February.The prevalence of women worldwide who experience heavy menstrual bleeding ranges anywhere between 15%-to-61%, noted Dr. Sholzberg. A more-accurate estimate does not exist, she explained, because defining and quantifying heavy menstrual bleeding is very challenging.“Heavy menstrual bleeding is generally defined as blood loss greater than or equal to 80 millilitres of blood per menstrual cycle,” she said. “I stand here still as a woman of reproductive age—I have no idea what that means.”Existing methods for quantifying vaginal blood loss are flawed, including using menstrual products as a proxy. Until only very recently, in 2023, the true amount of blood contained by menstrual products was unknown, because the volume was tested with saline, explained Dr. Sholzberg.“We’ve all seen those commercials on TV with the blue liquid. Right? There’s a problem: blue water has a completely different viscosity than blood,” she said.Last year, a group of scientists from Oregon Health & Science University conducted a study on the absorbency of period products using expired units of red blood. The study found that the volume of blood held in different menstrual products varied significantly. “This means that it’s really hard for physicians to truly assess how much blood someone’s losing if you’re just using the amount of products that somebody’s going through in a day alone as the proxy for how much they’re bleeding,” Dr. Sholzberg said. “So if clinicians are relying on the frequency of product changing alone to diagnose heavy menstrual bleeding, we are missing a significant amount of women.”Because of how difficult it is to quantify heavy menstrual bleeding, Dr. Sholzberg said that in addition to using the Pictorial Blood Loss Assessment Chart (PBAC, a “semi-quantitative” visual assessment of blood loss), she asks her patients many questions, including: “Are you getting up in the middle of the night? Are you doubling up? Do you have to sit on the toilet to bleed? Do you pass clots? Do you flood?”Ultimately, if the patient says they experience heavy menstrual bleeding, that is enough information for a diagnosis, Dr. Sholzberg explained in an interview with the Medical Post.“If a patient says I have heavy menstrual bleeding, believe her. So that belief is really important. Her saying it's abnormal is sufficient. It's sufficient, right? Because it's very unusual for a woman to flag that,” she said.“The bottom line is, heavy menstrual bleeding that is negatively affecting somebody's quality of life, that is interfering with their ability to participate in school or work or their social activities. These are all things that should qualify as the diagnosis of heavy menstrual bleeding.”

‘Really hard for physicians’: Is your patient experiencing heavy menstrual bleeding?

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